Operative report
Operative Report
An Operative Report (pronounced: op-er-a-tive re-port) is a detailed written account of a surgical procedure performed by a surgeon. It serves as a formal record of the patient's surgical history and can be used for future reference, quality improvement, and legal purposes.
Etymology
The term "Operative Report" is derived from the Latin word "operari" meaning "to work" and the Old French "reporter" meaning "to bring back".
Structure
An Operative Report typically includes the following sections:
- Preoperative Diagnosis: This section includes the diagnosis made before the surgery based on the patient's symptoms, medical history, and diagnostic tests.
- Postoperative Diagnosis: This section includes the diagnosis made after the surgery based on the findings during the operation.
- Procedure: This section describes the surgical procedure performed, including the type of surgery, the surgical technique used, and any complications encountered during the surgery.
- Findings: This section includes the surgeon's observations during the surgery, such as the condition of the tissues, the presence of any unexpected findings, and the results of any intraoperative tests.
- Surgeon: This section includes the name of the surgeon who performed the operation, as well as the names of any assisting surgeons or surgical residents.
Related Terms
- Surgical Procedure: A method or course of action designed to achieve a particular result in the treatment of a condition or disease.
- Surgical Technique: The specific method or procedure used by a surgeon to perform a particular operation.
- Intraoperative: Pertaining to the period during a surgical operation.
- Postoperative: Pertaining to the period after a surgical operation.
External links
- Medical encyclopedia article on Operative report
- Wikipedia's article - Operative report
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